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, �.�d� <br /> ` � City of Qrono <br /> Building Permit Application for Internal Wo�k <br /> ' (windows, doors, siding, re-roof, etc. <br /> ����A�^�= Pertnit number: D /�DD 7 <br /> O.���O PO Box 86 <br /> Crystel Bay,MN 55323-0088 Dace reoeNed: `J o7 / <br /> S'!►eet Addrass: Received by: <br /> � � 2750 K�Iley Pa�kwaY Plen rovisw fee: <br /> Orono,MN 55356 <br /> Total Fes: ����Q� <br /> Main: 852a49-46Q0 Fax: 952-249-4616 www.ci.orono.mn,us <br /> Thls appik�fion fiorm must be completed in full and all required iMorn►atlon must be submitted_ <br /> Incomplebe sppllcadons wlll be retumed. (Please pMnt) <br /> GENERAL INFORMATION: � <br /> Job Si�e Addr�ess: S Q ��d Sfy�� C�lG r� <br /> YVIII thls bo a Perade of Homss�Ramod�lws 8howe�e Hon�e or othe�Dlaplay Home? Yss No <br /> l�y�,e s,pedal�resnt pemxY it repuirod wlFh Adke Deperbnent enal C�y G�w�dl aPAroval 80 d�ys Pvbr b the e►rerrt. Sht�Ae bus sarolaa wYl be <br /> reyukee w►leas epp�canf Qen,ons�raNs s�uVlkierd on.�3e varking!9 avaNaers. nron peminred everrts w�na oe a�orred_ <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: �1���/�St �odF�1�9 S'��� �hdo�.6 LnG <br /> State uoense# 2 DO!p '77 Expire�on oate: p3t 3i0 b1 Or�_ <br /> Leed CerdficaUon Number: Expiraaon Date: <br /> rybr wv►k on honws�t w�►e a��abw�sd p►!w to 1978 <br /> Pl,oi,e: 76 3_�l a 7-q r•q 6 c��) ?6 3-o18v— l3� � c�u� <br /> Mailing Address: S/ r�.fk �`l~ Clty: c�Z ZIP: S'S3 64' <br /> Contact Pe►son: /�nn/� �Pr,�G.� Applicant is: n / Homeowner �cwa.o�.� <br /> Ema11 a�dlor Fax: 763 � '7 N 7� ��O/ <br /> �y,�_. <br /> PROPER7Y OWNER INFORMATION: <br /> Name: �hr�'��'� l,t �OS'.Soti' <br /> Pho�e(day): <br /> nddress_ sr, �.��c S� Cr�c���' ��h�:l.������v ziP: <br /> EmaA and/cx Fax <br /> PROJECT INFORMATIGN: <br /> ryp.or Pro� a+y sara�mov.m.nt may requ�re <br /> ❑Door(s) Q Remodal []Water Demaye , MCWD rovls�v 8 psrn�its: <br /> MMneheha Creek Wetershed Diserict(MCWD) <br /> O W�($) O�ir p swrm�arnage 18202 Minnebnka BNd <br /> ❑Slding ❑Restoration ❑Other_(speafy) �P�,MN 55391 <br /> Phone: 952�71-0580 <br /> �$Re.roo( ❑Flre Damage Fax: 952-a71-0682 <br /> www.minnehahacreek.orca <br /> Overatl Pro)act Description: <br /> Fstimated Construation Valuatlon of Projec!(exduding land) S �cav <br /> APPLICANT ACKNOWLEDGEMENT: <br /> A�ees b provide all infa�medon required or requested by the Building Departrnent; <br /> Certifies that Ihe irribmnatlon supplied ia true end comact�o the best of his/her knowledge. The applicar�t recognaes thet they <br /> ere solely responsible for submlttln9 a comp(ete appl�etlon being aware that upan fsilure to do so, ats staff Mas no slbemative <br /> but co reject It untll n is comple�Ee� <br /> Some or a8 of ths informatian thst you ero eakad to provide on thls applice6on is dassifiad by State law as eld�ar private o� <br /> conAde►�ial. Privaee data Is Irnom�tion which pener�lly cannot be givan to the publlc but aen be given to I�e subjoct of ti� <br /> data. Confidentla� date is infomiadon whld� generelly cannat ba �iven ro either th� public �the subject of the dats. Our <br /> pu� and inoerMed uee of ihis iniormedon is do ennuelly update our recor� and r000rds of oTher govemmeMal agencles <br /> uired Iaw. If u to su the InFormation the ' n me not be issued. <br /> APPiicant's Signature: � Date: ���y�-�� <br /> �aetuveeoed_ oa-o�-2ot� <br />